West London Coroner’s Court

Baroness Chapman of Darlington Excerpts

Wednesday 16th December 2015 Westminster Hall

[Jenny Chapman (Darlington) (Lab)]

It is a pleasure to serve under your chairmanship, Sir Roger. I am astounded by the humanity, sensitivity and care with which Members have presented cases on behalf of their constituents. I cannot think of anything more distressing for someone who has lost someone dear to them than having to deal with such poor administration as some constituents have had to endure. I congratulate the hon. Member for Kingston and Surbiton (James Berry) on securing the debate and on the incredibly sensitive manner with which he presented his argument. I was also struck by my hon. Friend the Member for Ealing North (Stephen Pound), who normally speaks with great humour and characteristically puts a lot of anecdote into his speeches. There was not one shred of humour today, such is the seriousness of the case he was arguing.

We seem to be having three different problems with West London coroner’s court: errors on certificates; delays; and, rudeness, lack of care and poor communication with families. I will not go into specific cases in detail, but some of the comments that the families have made are useful in illustrating the problems. One said:

“After months of emailing I finally got a reply but my complaints were not acknowledged. In July this year I finally got the post mortem report riddled with mistakes. Talking about my daughter and referring to my mum as ‘miss’. It was harrowing enough reading but the mistakes made me feel that my mum was just another body.”

Another family said about a very young child:

“My granddaughter’s baby boy died on the 3rd of January this year. And she still has not had a death certificate or told why he died. He was 11 weeks old and she is still devastated.”

Another said:

“This was after they had put my late father’s place of birth as my mother’s home address. We still haven’t been getting full responses to emails and it’s only been 4 1/2 months since my father died, so I expect they won’t have the inquest in the next year, let alone get a full death certificate. They are an utter disgrace.”

Some people know more about this issue than MPs: funeral directors. I cannot imagine the frustration that funeral directors must be experiencing. One said that

“my heart sinks when we have to call them. To stand a chance of getting a reply we call at 7am and they answer around 3pm! It’s awful when other calls come in and all people can hear in the background is ‘your call is number ** in the queue’!”

It is maladministration, it is bad practice, and it is insensitive. It is not good enough and it should not be happening in this country in 2015.

As my hon. Friend the Member for Ealing North said, we are looking at a structural failure and a failure of leadership. It is surprising to families when they discover that it is difficult to know where to complain. There are many organisations with a hand in the issue, such as the council and the Metropolitan police. It is unfortunate that the hon. Member for Uxbridge and South Ruislip (Boris Johnson) has had to leave, because I would have been interested to hear an intervention from him.

[Dr Huq]

The hon. Member for Kingston and Surbiton (James Berry) referred to the ITV News investigation. One of the emails I have from the coroner says that

“this complaint is fuelled by the recent unbalanced ITN news items.”

That is what I mean by the inability to take criticism—someone who is grieving has been pooh-poohed by the coroner saying that it is media manipulation.

[Jenny Chapman]

I was not aware of that as I am from the north-east and I do not watch the local news when I am down here. What my hon. Friend says gives a good indication of the lack of care and sensitivity that has been experienced by families who have to access the service at such a devastating time. It seems odd to me that councils and the Met provide admin staff support, but do not have responsibility for the overall service. That confuses families at a time when they should not be expected to find their way through some web of the civil service.

I will not speak for too much longer, because I want to give the Minister as much time as possible to explain what she intends to do to put that right. As my hon. Friend the Member for Hammersmith (Andy Slaughter) has indicated, the council has called for the JCIO to investigate.

[Stephen Pound]

I want to put something seriously on the record, bearing in mind what my hon. Friend has just said, before the Minister responds. The debate is more in sorrow than in anger. It is not an attack on the Government in any way, shape or form. We are absolutely united here. The tone struck by my hon. Friend is exactly the right one. We are not seeking to blame the Government, but we are looking for some hope from the Government on how this situation can be resolved with the greatest expediency.

[Jenny Chapman]

That is exactly right. I know the Minister will care deeply about this and will want to respond and put this matter right as quickly as she possibly can.

The JCIO will let us know in January whether it intends to conduct a full investigation into matters in west London. I sincerely hope that it agrees to do that, and I hope that it is done in a timely fashion so that families who are currently experiencing delays can have their cases heard as quickly as possible, and so that the wider community can have confidence in the service. That is something the Minister will care deeply about and want to put right. I will stop now so that she has as much time as possible to let us know exactly what she intends to do.

--- Later in debate ---

[Caroline Dinenage]

That was all included in the coroner reforms. If the hon. Lady gives me just a little time, I am about to talk about them.

As I said earlier, bereaved people must be at the heart of the coroner service, and that was the key aim of the reforms in the Coroners and Justice Act 2009. The coalition Government implemented those reforms, including the rules and regulations that underpin the Act. The provisions came into force in July 2013 and introduced the role of the Chief Coroner. In September 2012, his honour Judge Peter Thornton QC was appointed as the first Chief Coroner. He has already played a central role in providing guidance for coroners on the new national standards for coroners set out in the legislation. Coroners are now required, for example, to conclude an inquest within six months of a death being reported to them, or as soon as practicable afterwards. They are also required to report coroner investigations that last more than 12 months to the Chief Coroner, who is in turn required to report on that to the Lord Chancellor and to Parliament in his annual report.

For bereaved people and families, the most significant development under the 2009 Act was perhaps the “Guide to Coroner Services” booklet, a document published by the Ministry of Justice that sets out the standards of service that people can expect from coroners’ offices and what they can do if they feel that those standards are not being met. It is vital not only that coroners know what the standards are, but that bereaved people understand how a coroner’s investigation is likely to proceed. The guide is accompanied by a shorter leaflet that sets out the key aspects of an investigation. We have sent hard copies of the guide and the leaflet to every coroner’s office in England and Wales so that they can be given to every bereaved person or family. The guide is also available on the gov.uk website.

[Jenny Chapman]

What the Minister is saying is very interesting, but we are talking about a service that has failed. It has been failing, persistently, for some time. It has been flagged to any authority that anyone can think of, yet we have seen the failure continue. What does she think she might need to do to ensure that we do not have this kind of delay in taking action should such a situation arise again in future?

[Caroline Dinenage]

A lot of the reforms that were part of the changes over the past two or three years will begin to take effect soon. There are obviously a number of issues at play here. We are dealing with a situation where someone is already under investigation. That may well continue, so there are a number of things to consider.

I shall make some progress because I want to address in full the concerns raised by my hon. Friend the Member for Kingston and Surbiton about the provision of out-of-hours coroner services. I am aware that faith communities, particularly the Jewish and Muslim communities, are concerned about the lack of an out-of-hours service because that can delay the timely burial of their loved ones required by their faith. As part of our commitment to improve coroner services, we have recently completed a post-implementation review of the coroner reforms that we implemented in 2013, seeking views on, among other things, the availability of out-of-hours services. We have now received all the responses, which are being analysed, and I hope to come back to the House with a report in spring next year.

While the review was ongoing, we also worked with London local authorities and the Metropolitan and City of London police to develop a pan-London out-of-hours service. The police and local authorities are now also planning to commission a more general review of coroner services in London to see how resources can be better shared and managed to streamline and improve both in-hours and out-of-hours services in the hope that that will also address some of the issues raised by Members today.

On deprivation of liberty safeguards, my hon. Friend the Member for Kingston and Surbiton raised concerns about additional distress caused to families and the pressure put on coroners’ workloads by their having to conduct inquests into the deaths of those who were under a deprivation of liberty safeguard when they died. The safeguards frequently occur in care homes or in long-term hospital care, even when someone quite plainly dies of natural causes. That is because of a Supreme Court decision last year that held that such individuals are effectively in custody when they die, which is a category of case that coroners are under a statutory duty to investigate. With that in mind, I have been speaking to the Minister for Community and Social Care. We agree that we need to do what we can to solve the problem as a matter of urgency. My officials, together with their counterparts from the Department of Health, are looking at how we can remove the burden while maintaining the protections put in place for those who truly are in state custody.

I am grateful to my hon. Friend the Member for Kingston and Surbiton for all the matters he raised today and to all those who have raised concerns about the West London coroner’s court, out-of-hours services and the deprivation of liberty safeguards. I have welcomed the chance to hear more details about such concerns. I have set out measures that will lead to improvements across the country, but we will continue to monitor and will be grateful for feedback as we move forward.

Question put and agreed to.

Resolved,

That this House has considered standards of service at West London Coroner’s Court.